No abstract

Tropical diseases remain a significant threat to deployed military personnel as demonstrated by recent outbreaks amongst troops in Sierra Leone, Iraq and Afghanistan. Five cases are presented from military deployments in tropical or sub-tropical areas, which illustrate important diseases and diagnostic principles for military physicians.

A 44 year old man was admitted with a history of intermittent jaundice and rigors. Three months previously he had been admitted to another hospital with similar symptoms and half a stone (3.2 kg) weight loss. At this time his problems were thought to be secondary to choledocholithiasis. At operation, gallstones were seen in the common bile duct with an associated lower common bile duct stricture. He underwent cholecystectomy and choledochoduodenostomy. The symptoms initially resolved postoperatively but subsequently recurred on an intermittent basis. He was transferred to our hospital for further management of his problems.He had a 28 year history of ulcerative colitis, based on barium enema, which had remained quiescent for many years on salazopyrin maintenance treatment. His past medical history included segmental bronchiectasis secondary to childhood whooping cough. He was a life long non-smoker and did not drink alcohol.

This case illustrates an athletic 22-year-old, who presented to the hospital with a 3-week history of spontaneous right arm ache, discolouration and swelling. His blood tests were normal, with a negative D-dimer (<150ng/ml). He underwent a CT venogram for suspicion of venous obstruction which was unremarkable. However due to a high clinical suspicion, an ultrasound doppler was performed. This identified the presence of axillary-subclavian thrombosis which in conjunction with other clinical and radiological parameters confirmed the diagnosis of Paget-Schroetter Syndrome (PSS). Our patient was commenced on anticoagulation as the venous obstruction was suspected to be sub-acute with clinical suggestion of collateral formation. Unfortunately, his symptoms failed to resolve over a 6-month period, and he underwent an elective right rib resection with right subclavian bypass using the great saphenous vein with good outcome post-operatively. PSS is a rare manifestation of venous thoracic outlet syndrome (TOS) commonly seen in young, healthy, athletic individuals. Despite the high effectiveness of D-Dimers in ruling out acute thrombotic process and the accuracy of dedicated CT angiography in excluding vascular thrombotic events, both tests proved inconclusive in this particular case. This latter observation highlights the importance of the clinical context, and risk profiling in guiding results interpretation.